Evidence for fluid therapy in sepsis and septic shock is also limited. Goal-directed resuscitation during the first 6 hours is recommended by the Surviving Sepsis Campaign Guideline (SSCG), based on two randomized controlled study. Fluid challenges are one of the methods used to achieve the goals, with administration of fluid boluses and initial higher volume of intravenous fluids. Due to its inclusion in guidelines1, early goal-directed therapy (EGDT) and fluid challenges have now become common clinical practice in resource-rich countries. On the other hand, the efficacy of large fluid bolus resuscitation is questioned because of low level of evidence for physiological support and lack of clinical controlled trials comparing fluid bolus therapy versus no fluid bolus therapy. The variable availability of mechanical ventilation must be considered when making recommendations for fluid resuscitation. Since access to mechanical ventilation is often limited in developing world settings, the recommendations in the SSCG are not applicable in this context without additional evaluation. Recently, the FEAST trial in East African children with compensated shock in severe malaria and sepsis revealed that fluid bolus therapy of 20 to 40 mL/kg body weight caused a dramatic increase in case fatality. Several studies have found positive fluid balance to be associated with increased mortality in sepsis or septic shock. A retrospective study (the VASST study) included 778 patients with septic shock showed that there is significant correlation between a more positive fluid balance at both time points of 12 hours and day 4 and increased mortality. In the SOAP study, multicenter prospective cohort study enrolled 1177 patients with sepsis, cumulative fluid balance within first 72 hours after the onset was an independent predictor of mortality. Also, a prospective observational study of 164 patients with septic shock reported that there was no significant difference in 90-days mortality between patients with higher fluid volume infused (> 4.0 L) and lower volume (< 4.0 L) on day 1. They concluded that initial fluid volume administered was not associated with mortality in patients with septic shock. Optimal initial fluid volume and strategy in sepsis and septic shock is thus unclear. Especially in resource-limited countries, fluid overload is more dangerous than that in resource-rich countries, because development of pulmonary edema and ALI/ARDS is almost always fatal in settings without access to mechanical ventilation. The recommendation of fluid bolus resuscitation therapy as promoted in the SSCG should therefore be evaluated cautiously in the resource-poor setting.